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Boards: Immunology/Hemolymphatic > IMHA consensus > Flashcards

IMHA consensus Flashcards

1
Q

What is more accurate in a state of agglutination, calculated hematocrit or spun PCV?

A

PCV

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2
Q

List causes for non-immunemediated spherocytosis (6)

A
  • oxidative damage (zinc or acetaminophen toxicity)
  • envenomation
  • hypersplenism (hepatosplenic lymphoma)
  • pyruvate kinase deficiency
  • erythrocyte fragmentation (endocarditis, hemangiosarcoma, hemolytic uremic syndrome)
  • dyseryhtropoiesis
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3
Q

What is the cutoff number for spherocytes/x100 oil immersion field to be supportive of IMHA in dogs?

A

> 5 is considered supportive (65% sensitive, 95% specific in one study)

3-4 may be considered as well (3/field 74% sensitive and 81% specific)

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4
Q

In what situations should SAG be confirmed with 3x erythrocyte washing and repeated SAG in 1:4 saline?

A
  • equivocal results of SAG
  • markedly increaed TP
  • high fibrinogen cc
  • strong ruleaux formation on blood smear
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5
Q

What are the two options for demonstrating anti-erythrocyte antibodies?

A

direct coombs’ test
flow cytometry

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6
Q

How does immunosuppression or prior transfusion affect coombs’ testing?

A

immunosuppression is unlikely to immediately cause negative coombs’ tests but recommendation is to draw sample before administration

blood transfusion can cause false positive coombs’ test results

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7
Q

What do ghost cells indicate?

A

intravascular hemolysis

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8
Q

List potential pathogens causing IMHA in dogs and cats and their evidence for causation

A

dogs:
medium to high evidence: Babesia
low evidence: Anaplasma
others all negliglbe to low, but mention technically any infection can cause IMHA so full tick-borne panel is still indicated

cats:
medium evidence: Babesia felis
high evidence: Mycoplasma haemofelis
low: FeLV

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9
Q

What is the recommendation for infectious disease screening in dogs with IMHA?

A
  • Babesia should be tested for with PCR and serology - recheck negative dogs if high exposure risk
  • test for Heartworm infection - can cause positive coombs’ and anemia
  • to be strongly considered: other vector-borne diseases: Anaplasma, Bartonella, Ehrlichia, only if endemic: Leishmania
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10
Q

What is the recommendation for infectious disease screening in cats with IMHA?

A
  • If endemic: Babesia felis
  • PCR for M. haemofelis, if available all 3 mycoplasma species
  • FeLV/FIV testing
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11
Q

What qualifies as diagnostic for IMHA?

A

Anemia

PLUS

  • 2 or more signs of Immune-mediated destruction (spherocytes, positive SAT without washing, positive coomb’s or flow cytometry) OR positive washed SAT

PLUS

  • 1 or more sign of hemolysis (hyperbilirbunemia, biliuria, icterus etc.; hemoglobinuria, hemoglobinemia, ghost cells)
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12
Q

What is supportive of IMHA provided another cause of the anemia cannot be found?

A
  • 1 sign of immune-mediated destruction (SAT, coombs’ or flow cytometry positive)

PLUS

  • 1 or more signs of hemolysis
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13
Q

How fresh should pRBC units be for transfusion in IMHA?

A

ideally fresh i.e., 7-10 days. can consider older units if fresh ones are not available but increaes the risk of complications and mortality

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14
Q

Why is pRBC or WB preferred over bovine hemoglobin solutions?

A
  • BHS scavenge NO –> acitvating platelets, causing vasoconstriction –> risk of hypertension
  • BHS higher colloid osmotic pressure than pRBC or WB –> risk of hypertension
  • shorter circulating life than pRBC
  • increased risk of mortality shown
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15
Q

When is it recommended to start a second immunosuppressive drug in IMHA?

A
  • severe disease (BUN and tbili recommended as markers)
  • PCV not stable during first 7 days of treatment (i.e., drops more than 5% in 24 hours)
  • transfusion dependent after 7 days of treatment
  • considered at risk for severe adverse effects from glucocortcoid use
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16
Q

What are the recommended 2nd line immunosuppressive drugs (4)?

A
  • Azathioprine
  • Cyclosporine
  • Mycophenolate mofetil
  • Leflunomide
17
Q

Which immunosuppressive drug is not recommended for IMA in dogs?

A

Cyclophosphamide

18
Q

When is IVIG recommended in dogs with IMHA?

A

if the patient fails to respond to 2 immunosuppressive drugs

salvage, not routinely recommended

19
Q

When and how is tapering recommended?

A

PCV/Hct stable and > 30% and clincially improved for at least 2 weeks, then:
* taper Prednisone by 25%
* do not change second drug, but if second drug used: can consider faster tapering of prednisone

  • continue to taper Prednisone by 25% every 3 weeks (or more reduction and every 2 weeks if other drug administered)
  • do not start tapering 2nd immunosuppressive drug until prednisone fully weaned. then: either give 4-8 more weeks and stop without tapering or taper with same protocol as prednisone
20
Q

How should IMHA patients receiving prednisone be monitored?

A
  • UA +/- culture every 8-12 weeks
  • PE for adverse signs
  • obtain baseline biochemistry values
21
Q

How should IMHA patients receiving Azathioprine be monitored?

A
  • CBC and liver values every 2 weeks for first 2 months, then every 1-2 months
22
Q

What are adverse effects of azathioprine?

A
  • gastrointestinal signs
  • severe hepatotoxicity - develops within first few weeks of treatment
  • myelosuppression - can be delayed
23
Q

How should IMHA patients receiving cyclosporin be monitored?

A
  • monitor for GI adverse effects and gingival overgrwoth
  • chemistry every 2-3 months (risk of hepatotoxicity)
24
Q

What are the adverse effects of cyclosporin

A
  • GI signs (give frozen or with food to alleviate this!)
  • hepatotoxicity - idiosynchratic
  • hypertrichosis
  • gingival hyperplasia

advantage: not myelosuppressive

25
Q

What could increase the risk of cyclosporin overdose?

A

metabolized by the cytochrome P-450 system –> if other drug using this pathway is administered

26
Q

How should IMHA patients receiving mycophenolate be monitored?

A
  • for GI signs
  • CBC every 2-3 weeks then every 2-3 months
27
Q

What are the adverse effects of mycophenolate mofetil?

A
  • GI signs
  • ulcerative colitis
  • myelosuppressive - potentially
28
Q

How should IMHA patients receiving Leflunomide be monitored?

A
  • CBC + liver values every 2 weeks for 2 months, then every 1-2 months
29
Q

What are the adverse effects of Leflunomide?

A
  • GI signs
  • increaed liver acitivity
  • occasionally: hepatotoxicity, pulmonary lesions, cutaneous drug reactions
30
Q

At what neutrophil cutoff are prophylactic antibiotics indicated?

A

< 1000 cells/microL

31
Q

What is the recommendation for symptomatic neutropenic patients?

A
  • try to indentify source of infection
  • 4 quadrant Abx coverage
  • IV fluids and hemodynamic monitoring
  • recombinant granulocyte colony stimulating factor if overdose of immunosuppressant caused neutropenia to last > 1 week
  • stop myelosuppressive drug and if needed start different one after recovery from neutropenic episode
32
Q

When is a splenectomy recommended in IMHA?

A
  • dogs requiring continuous immunosuppressive therapy
  • dogs suffering repeated relapses
  • only if infectious etiologies have been exhaustively excluded
33
Q

At what platelet count cutoff is thromboprophylaxis considered contraindicated?

A

PLT < 30,000 /microL

34
Q

What has shown to increase the risk of thromboembolic disease in dogs with IMHA?

A
  • intravascular hemolysis
  • autoagglutination
  • marked leukocytosis
  • increased liver enzyme activity
  • higher dosease of glucocorticoids
  • IVIG administration
35
Q

What is the recommendation for antithrombotic tx in dogs with IMHA?

A
  • unfractionated heparin +/- antiplatelet drug

if not feasible or available:
* factor Xa inhibitor or LMWH

if not available or feasible:
* antiplatelet drug (clopidogrel over aspirin)

36
Q

How long should antithrombotic therapy be administerd for?

A

until the patient is in remission and no longer receiving any glucocorticoids

37
Q

When are dogs with IMHA at the highest risk of thromboembolic events and mortality?

A

first 2 weeks after initiation of treatment

38
Q

When is empirical abx treatment for vector-borne disease recommended for dogs with IMHA?

A
  • only if the dog has a high risk of infection (geographic location, lifestyle, travel history)

Boards: Immunology/Hemolymphatic (12 decks)

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